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Australian health IT sage looks back to the future and sees what went wrong

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He’s a visionary in the field whose seminal 2004 BMJ paper predicted the ways healthcare would be transformed by technology, but as we approach his 2020 deadline Professor Enrico Coiera says companies have held back progress and patients are still being put at risk.

It must have seemed such a long way away, but Coiera boldly foretold the future when he described a 2020 in which technology was assimilated into clinical practice.

“The world may be such that as a clinician you work in flexible virtual teams and some of your colleagues are computers. You would of course instinctively mistrust clinicians who always know the answer without consulting the information grid, and patients often choose to be the team leader,” Coiera, now Foundation Professor in Medical Informatics at Macquarie University and Director of the Centre for Health Informatics, wrote in 2004.

“Keyboards are banned as harmful and can be found in museums, next to punch cards and spittoons. The health record is a direct multimedia history of conversations, and a software agent is its curator. For the still cognitively limited clinician, your earring whispers your patient’s name when you meet.”

Keyboards remain and earrings are yet to whisper, but Coiera has greater disappointments when it comes to the pace of change.

“In terms of the IT that doctors use, compared to today you wouldn’t see much difference, to be honest. Many of the electronic record systems that people use in hospitals today feel pretty much like the systems of back then,” he told Healthcare IT News Australia.

“The problem with ‘clunky’ user experiences for medical record systems is that people may not enter the data as much as they should or as well as they should or they omit things. There are also lots of people doing cutting and paste, rather than writing new notes, and that brings in errors.”

The responsibility for retro interfaces and user dissatisfaction, he believes, lies with the companies that put profits before patients.

“It’s really a problem with industry, in the sense that there has been very little drive to improve user experience and there’s been a lot of money made in just simply rolling out the systems they have,” Coiera said.

“One of the reasons the companies have done so well is they’ve locked in customers. So, if you buy a particular system, then all your data sits on their proprietary database and it’s very hard to get it out. And so it’s very hard to connect it up to a new system – a big barrier.”

In his article of 13 years ago, Coiera wrote that despite the expertise of the rising field of health informatics its practitioners were being sidelined by those in industry, healthcare and government unwilling to listen or resistant to change.

“The profane ground of health informatics, still mostly shunned, is the world of politics, culture and persuasion, complaints from users when systems disappoint them, the messy craft of system implementation, which requires different tactics from one site to the next, and our unacceptably high number of system failures.”

So the man on the vanguard devised four rules to help guide the design of revolutionary, intuitive and interoperable health technologies.

Rule 1: Technical systems have social consequences

Rule 2: Social systems have technical consequences

Rule 3: We don't design technology, we design sociotechnical systems

Rule 4: To design sociotechnical systems, we must understand how people and technologies interact.

A medical doctor with a PhD in computer science was perhaps an appropriate health informatics prophet — and the intervening years have seen astonishing developments in apps, social media, electronic health records and data analytics — but Coiera may have overestimated the likelihood that he and his peers would guide the revolution.

Even in the fundamental area of safety, they can be ignored.

“We’ve been saying since about 2003 that health IT is mission critical and if it goes wrong, you could hurt patients,” he said.

“We still don’t, for example, in Australia have any national way of testing or certifying that systems are safe. Which is a surprise, since we’ve been asking about it for more than 15 years. So that’s a disappointment, and I do worry that we might be unnecessarily risking patients’ care because we’re not focusing on safety — still.”

For the author of the influential Guide to Health Informatics, now in its third edition, it defies reason that healthcare lags behind other industries in focussing on keeping people safe with its IT systems.

“If you were in an aeroplane or in the nuclear power industry, you would design your system to be mission critical, which means that even if something fails, something else will be there and back up straight way,” Coiera said.

“A lot of hospitals don’t design their systems in a mission critical way. We know that when a computer network goes down in a hospital that care gets affected. We know that tests don’t get ordered or get ordered twice, drugs get ordered twice, don’t get ordered or get given twice.”

Coiera’s team at Macquarie University has been working to combat this by analysing data from systems failures in Australia, the US and the UK and developing a pioneering “classification of IT harms” that catalogues the different risks.

The team is also developing an IT monitoring system that will detect hospital network malfunctions in real time and alert users, enabling faster response times.

It’s important work in a day and age in which, unlike 2004, healthcare has been transformed by digital technologies. It’s one of the greatest successes of the intervening years.

“You can’t run a modern health system without it being digital. So that’s a big change, and a big win.”

With that comes the power to demand the development of sociotechnical systems by companies that are fit for purpose.

“Before, people probably would have taken what they were offered, or didn’t understand enough to demand what they needed. Now I think that user base is much more sophisticated and I think the vendors have no choice but to lift their game,” Coiera said.

“The users — that’s us — have to be more demanding of that from the vendors.”